BCC Minutes 05/25/2023 WMay 25, 2023
1
MINUTES OF THE COLLIER COUNTY
BOARD OF COUNTY COMMISSIONERS
STATE VETERANS’ NURSING HOME WORKSHOP
Naples, Florida, May 25, 2023
LET IT BE REMEMBERED that the Collier County Board of County
Commissioners, in and for the County of Collier, having conducted business herein,
met on this date at 3 p.m. in WORKSHOP SESSION in Administrative Building F,
3rd Floor, Collier County Government Center, Naples, with the following members
present:
CHAIRMAN: Rick LoCastro
Chris Hall
Dan Kowal
William L. McDaniel Sr.
Burt L. Saunders
ALSO PRESENT:
Amy Patterson, County Manager
Jeffrey Klatzkow, County Attorney
John Mullins, Director, Communications, Government & Public Affairs
Troy Miller, Communications & Customer Relations
COLLIER COUNTY
Board of County Commissioners
STATE VETERANS'
NURSING HOME
WORKSHOP AGENDA
Board of County Commission Chambers
Collier County Government Center
3299 Tamiami Trail East, 3rd Floor
Naples, FL 34112
May 25, 2023
3:00 PM
Commissioner Rick LoCastro, District 1; - Chair
Commissioner Chris Hall, District 2; - Vice Chair
Commissioner Burt Saunders, District 3
Commissioner Dan Kowal, District 4; - CRAB Co -Chair
Commissioner William L. McDaniel, Jr., District 5; - CRAB Co -Chair
Notice: All persons wishing to speak must turn in a speaker slip. Each speaker will receive no more than three (3) minutes.
Collier County Ordinance No. 2003-53 as amended by Ordinance 2004-05 and 2007-24, requires that all lobbyists shall,
before engaging in any lobbying activities (including but not limited to, addressing the Board of County Commissioners),
register with the Clerk to the Board at the Board Minutes and Records Department.
1. PLEDGE OF ALLEGIANCE
2. WORKSHOP TOPICS
2.A. PRESENTATION: MIKE KOLEJKA AND NEIL TERRY WITH ORCUTT
WINSLOW, WHO SPECIALIZE IN DESIGNING NEW AND RENOVATED
STATE VETERAN HOMES AROUND THE COUNTRY, WILL DISCUSS
MODELS OF VETERAN HOMES CURRENTLY BEING BUILT. THEY WILL
ALSO DISCUSS THE U.S. DEPARTMENT OF VETERANS AFFAIRS (USDVA)
REQUIREMENTS AND EXPECTATIONS FOR FACILITIES, WITH EMPHASIS
ON DESIGNS WITH ADDITIONAL SERVICES SUCH AS OUTPATIENT
THERAPY, ADULT DAY CARE, AND SHORT-TERM REHABILITATION.
2.11. PRESENTATION: STEPHANIE WALLACE, SENIOR VICE PRESIDENT OF
PROGRAMS FOR EASTER SEALS FLORIDA, AND JILL GENTRY, VICE
PRESIDENT OF PROGRAMS WILL DISCUSS EASTER SEALS' EXPERIENCE
OPERATING ADULT DAY CARES IN FLORIDA AND CONTRACTING WITH
THE USDVA FOR ADULT DAY HEALTH CARE SERVICES.
2.C. PRESENTATION: KURT MICHEELS, CONSTRUCTION PROJECTS
QUALITY MANAGER, DEPARTMENT OF MANAGEMENT SERVICES (DMS),
WILL OUTLINE THE DMS POLICIES FOR MOVING FORWARD WITH
CONSTRUCTION OF A FLORIDA STATE VETERANS' NURSING HOME.
2.D. PRESENTATION: BOB ASZTALOS, DEPUTY EXECUTIVE DIRECTOR,
FLORIDA DEPARTMENT OF VETERANS' AFFAIRS WILL ADDRESS NEXT
STEPS IN THE PROCESS, INCLUDING BUDGET DEVELOPMENT AND
FUNDING TIMELINES.
3. PUBLIC COMMENTS
4. ADJOURN
Inquiries concerning changes to the Board's Agenda should be made to the County Manager's Office at
252-8383.
May 25, 2023
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Anyone who needs a verbatim record of the meeting may request a video recording from the Collier
County Communications & Customer Relations Department or view it online.
Chairman LoCastro called the meeting to order at 3 p.m.
1. Pledge of Allegiance
Chairman LoCastro asked a veteran in the audience to lead the Pledge of Allegiance.
2. Workshop Topics
Chairman LoCastro said this is a very important topic and we’re excited about our state-funded
veterans nursing home. So much work has gone on behind the scenes and this was the No. 1
issue when we met with all the main players. This is a big project in Commissioner Saunders’
district and no one has done more on the inside, especially with his background, so he’s taking
the lead, but this is a Collier County project. Veterans from every district will be able to take
advantage of this wonderful opportunity, but we have a ways to go. He thanked everyone for
taking the time to come. We have a lot to talk about.
Mr. Mullins outlined the four presentations.
2.A. Mike Kolejka and Neil Terry with Orcutt Winslow, who specialize in designing new and
renovated state veteran homes around the country, will discuss models of veteran homes
currently being built. They also will discuss the U.S. Department of Veterans Affairs
(USDVA) requirements and expectations for facilities, with emphasis on designs with
additional services, such as outpatient therapy, adult day care and short-term
rehabilitation.
Mr. Terry told the BCC:
He’s been with Orcutt Winslow for over 37 years.
Orcutt Winslow is a national and international firm that recently merged with an
Orlando firm, so it has a local presence.
Our three main project types are healthcare, education and senior living.
Mr. Kolejka is our principal in charge of senior living, which also focuses on veterans’
homes.
We’ve designed over 50 veterans’ homes and remodeled over 20 nationwide, as far as
Hawaii and Virginia.
Our first veterans’ home was in 2009, when we worked for the state of Arizona in Tucson.
It was the first 120-bed veterans’ home that followed the federal VA’s guidelines for new
veterans homes.
State veterans’ homes get about two-thirds of their funding from the federal VA, which has
guidelines to follow to receive the appropriation.
Part of the guidelines is that they require a Small House concept, which divides veterans’
homes into pods, households of no more than 12 beds at a time. The idea is to center
bedrooms around living, dining and kitchen areas to create smaller units, so you have more
one-on-one care with caregivers, and it fosters social interactive action between residents.
Studies have shown this is a better approach to care. The only problem is it can be very
inefficient and that’s what he will discuss today.
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Once a home has been built and occupied for a year, we go back to conduct a post-
occupancy evaluation. We interview staff and residents to understand what works well and
what doesn’t. From that, we’ve evolved each of our designs to consider some of the things
that aren’t working.
We also work with each state to ensure we’re designing a home that works within state
parameters, rules or guidelines.
You’re going to see how these evolved. Mike, our principal in charge of Senior Living,
which oversees veterans’ homes, has been involved with all our veterans home projects to
ensure they have all the elements of good care and efficient designs.
Mike is considered a national expert and has presented to the National Association of State
Directors of Veterans Affairs and the National Association of Veteran Homes, so he can
talk about the project types and good designs.
Mr. Kolejka detailed a PowerPoint presentation and reported that:
We’re working on our 15th veterans’ home for the Utah Department of Veteran Affairs, a
new replacement home for 105 beds in Salt Lake City.
Part of our involvement today is to tell you about trends, what we’re seeing in the industry
and where we see state veterans’ homes going and where Collier County can find the best
concepts to move forward for veterans.
We have six offices and work from coast to coast, but also are working with Guam on a
veteran’s home.
We’re also building some adult day care, skilled nursing, assisted living, and we
reposition existing veterans’ homes and veterans cemeteries.
We have several key partnerships, including HMR, a South Carolina-based company that
operates a lot of veteran’s homes nationwide.
In addition to our post-occupancy evaluations, we’re creating a task force with HMR to
look at how we take the 15 homes we’ve done and push them to the next level for
operational efficiency while still maintaining the most important thing, resident
satisfaction, care and a great place for caregivers, who workday and night to care for our
nation’s heroes.
We want to share the latest designs for veteran homes. We’ve done two in Virginia that
were just completed – one in northern Virginia, about 30 miles west of Washington, D.C.,
and another in Virginia Beach. Both are open and operational, hold 128 vets and were
completed last year.
The homes use some of the key components of the Small House design concept, a
manageable household size, but we’ve tried to adjust it based on the post-occupancy
feedback to find out the sweet spot for the size of the household and how we can arrange
them in such a way that those households are able to be staffed.
One of the challenges now is trying to find caregivers and facility staff administrators.
Ever since the pandemic, the population of available staff has continued to shrink, while
competition, particularly in the private sector, has continued to grow, so we work hard to
ensure that as these designs evolve, we make them as efficient as we can for staffing,
doing more with less but not compromising on the quality of design or the quality of
resident care.
This is an outdoor therapy garden with half of a Chrysler 300 that we used as part of
outdoor training for residents, particularly with physical and occupational therapy.
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There are a variety of different flooring surfaces, with ramps and steps that allow residents
to exercise, particularly those who may only be staying in a home short-term before
returning home to their families. Some are permanent.
This is a simplified floor plan showing one of the iterations we developed about five years
ago, what the VA calls a community center, which is like a town center where a lot of
larger functions are performed, such as administrative offices, multi-purpose space,
physical therapy, kitchen, laundry, and all facility components, in addition to a coffee bar,
canteen, movie theater, etc. They’re equidistant from various residential households.
What’s on each side are neighborhoods. This design has four 16-bed households that make
up a neighborhood. At the center of the neighborhoods, with a linear passageway, is a
main-street promenade that’s the entry into each of the individual households. This
maintains a sense of community and a sense of house.
Think of these as 16-bed homes with an extended family. Within each is a kitchen and
living space accessible to all the residents and in the center are staff and support spaces,
including caregiver workstations that provide visual access to both households.
Since then, we’ve continued to evolve that design since it was developed about six years
ago. The next veterans home evolution, which we finished on Veteran’s Day last year, is
in Post Falls, Idaho. It’s a different layout.
Unlike other senior living communities with predominantly female populations, most
veterans’ homes are predominantly male, so the finishes and detailing are respectful and
appropriate for the population we’re serving as we’re looking ahead to the future as the
populations evolve.
[He detailed several photos showing the coffee shop, main-street promenade, community
center, church, a multi-purpose space, sports bar/canteen, with a billiard table, poker
chairs, sports club features, and a barber shop.]
The design creates a sense of privacy, but still allows visual connection front to back.
Within each of the households, one of the most important components for staff are the
carers, the frontline staff members caring for veterans every day. They also act as a
concierge and welcome visitors as they come into each household.
We’ve even introduced fireplace elements. Residence hallways feature lounges at the end,
with connections to daylight throughout, so you’re never going down a long, circuitous
corridor. Wayfinding is always very easy.
Each one has a living room with a visual connection to outdoor courtyards and other
outdoor amenities. The kitchen and dining are the heart of the home. There are induction
warmers set up so residents can sit in a household kitchen.
Choosing materials and finishes that are durable, long lasting and can take a lot of abuse is
important because many residents are in scooters and wheelchairs.
Like the Virginia facility, this 64-bed facility is designed to be expanded to up to 128 beds
by adding another neighborhood on the other side. We decided in this iteration, as we
continue to evolve, to look at staffing. Northern Idaho has a staffing shortage when it
comes to caregivers, so rather than having dining at the end of each corridor, a decision
was made to have one dining venue that serves two households, so you can serve double
the number of residents with the same number of staff.
Within each one is a little prep kitchen that allows them to cook made-to-order food, such
as omelets, toast, cheeseburgers, etc., that residents are looking for.
We’re looking at how we can consolidate things better without losing quality or care.
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Our latest project, Salt Lake Veterans’ Home, is a 105-bed home expected to be
completed in the first quarter of 2025. It has a distinct look that orients the entry to take
advantage of the Wasatch Mountains to the east of the Salt Lake City area, while also
creating a great open environment with a large front entry canopy and a multi-purpose
space that can be used for events. It opens onto a 6,000-square-foot event plaza, so the
space can spill out and accommodate motorbike rallies and food trucks. We’ve designed
entry courtyards to take advantage of those functions so residents can go outside and enjoy
them.
Some of the earlier veteran’s home concepts have a dedicated garden outdoors for each
house, but that also means you’re maintaining 10-16 different courtyards, whereas with
this concept, we’re looking at how we can do more with less without compromising
quality. We’re sharing a courtyard between two households and those living room spaces
open up onto those. We’ve also introduced shading elements and trees to ensure they’re
used. That’s part of the feedback we received. They need shade.
Within the community center, the promenade features resident amenities throughout and
brings in more daylight and connections to outdoor garden spaces. The more we can
connect with the outdoor environment, even for residents who may not be able to get
outside, it’s really important.
[He detailed the plan of the Salt Lake City home and its amenities.]
There’s a sports bar, coffee shop and connections to a theater, therapy and outdoor therapy
garden, a multi-purpose space, retail sales spot, barber shop and other amenities.
The design continues to evolve, and this concept uses two dining venues served by one
common kitchen, which helps reduce staffing. Rather than including the living room and
den in one space, we’ve moved those living and den spaces farther down to create activity
centers along the way as residents are traveling through.
We also introduced a connection corridor, which is mostly glass, and allows residents
when it’s too hot or it’s raining, to have a walking path around the shared households.
Another feature we’ve included is a lot of outdoor covered porches. Being able to get
outside in a safe way is important.
We’ve continued to evolve resident rooms over the last 13 years, and this represents the
latest and greatest iteration, where resident rooms are treated like a junior suite, like you
would see in a high-end hotel, where a caregiver can, in one glance, see the entire room
and survey to ensure residents are safe.
There’s a bed, a nightstand and headwall that provides medical gases, reading lights and
controls for lighting, TV and everything else in the room, as you would typically see in a
skilled-nursing facility. There’s a recliner and we’ve also introduced either a sofa bed or
an extended couch, which is important, particularly at end-of-life, when family members
may need to spend a night with a resident during difficult moments.
There’s also an armoire, a desk with a TV over it for ease of view, and a hand-washing
sink in each room, which is important for proper hygiene. There’s a spot for residents to
park a wheelchair or scooter for charging purposes with cabinetry above.
With bathrooms, we’ve looked at how to make them safe and ensure there’s a direct line
of sight from the bed to the toilet, which is important, especially for those with dementia
and Alzheimer’s care. There’s also a large shower that allows for ample service for
residents to be taken care of, particularly if they have mobility issues.
Another of our latest and greatest projects is the 126-bed Tennessee Veterans’ Home
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under construction outside Memphis, which is due to be completed next year. We’re
introducing a living and dining space for each household but doing it in a way that we can
share staff and resources between two households due to staffing challenges.
It’s designed for future expansion and features the promenade/main street and a large
outdoor event space for veterans to play pickleball, putt-putt golf, bocce, etc., in a secure
way and allow the public to come out for special events.
Two-wing neighborhoods utilize a shared kitchen between dining and living spaces.
What’s on our boards moving forward? Our Hawaii veterans’ home is due to be
completed next year, but we’re working now on a Maui veterans’ home, which takes some
of the same concepts we developed for the Salt Lake project, but doing it with a 60-bed
home due to the smaller population.
What’s unique is that it has an adult day healthcare program included as part of the
building and the VA is looking to move adult day healthcare forward. They’re providing
funding, so you can get two-thirds of the funding that you’d normally get for an inpatient
veteran’s home for every participant.
You can serve a larger population of veterans within an hour drive who may not yet be
ready to live in a skilled nursing facility, but because of either early-onset dementia, frailty
or other physical impairments, can’t be left at home while their adult children work or go
to school.
The adult day program is something many states have expressed interest in. A resident
usually comes in around 8 a.m. and usually stays until 3 p.m., so sometimes breakfast is
provided, and lunch is definitely provided, as well as a variety of activities. There’s a large
influx of people in the morning and leaving at the same time, so there are special design
constraints.
We’re also assisting the state of Nevada on its grant application for a new 128-bed home,
with the same concept of sharing a lot of amenities you’ve seen in the previous examples,
a shared kitchen, dining and living spaces, but shortening corridors to make shorter travel
distances so residents don’t have to go far down the corridor to get to the dining room,
living room or other courtyard spaces. It also locates the caregiver to provide a direct line
of sight to all major household components so they can do their job as efficiently as
possible without excess staff.
This also has one other feature for soiled linen and trash, which can be held here and then
picked up with a buggy and wheeled to a central laundry or trash, so you’re not taking
hazardous or offensive materials through the building and public areas. That population is
very sensitive to that.
Adult day healthcare could potentially be a component for Collier County. We completed
one in 2020 in the Phoenix area, a 99-participant adult day health program. Three
populations are being served – early onset dementia, young adults with traumatic brain
injury and seniors who potentially are a fall risk if they’re left at home by themselves
when adults and children or other family members are away.
A key component is that a large number of people arriving in the morning and leaving in
the afternoon, so we’re designing it for bus or vehicle drop-off with a large gathering
space at the building entry, where you check people in and out.
There’s also a theater, a large activity space, dining venues and separate activity spaces for
each of those populations, as well as a therapy component. It could be a freestanding
building, attached to a veteran’s home or potentially be retrofitted into an existing veterans
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home.
We’ve heard from some states that there may be an interest in taking underutilized areas in
existing skilled-nursing facilities, including a veteran’s home, and converting them to
outpatient or inpatient rehabilitation.
A project we did in Scottsdale, Arizona, called Pueblo Norte, was a traditional double-
occupancy, skilled nursing facility where you have two people in a room who share a
bathroom and there’s a shower room down the hall, an old-school, traditional skilled
nursing facility that was prevalent in the 1960s-1980s. The client realized there’s a great
unserved need for rehabilitation, so they asked us to renovate the building into all private
rooms with full bathrooms. There’s also a large activity space and a dedicated check-in
area for residents and visiting family members, as well as a large physical-therapy space.
[He showed photos of the main entry, reception area, corridor, private resident rooms and
large therapy space, which features a skylight to bring in daylight and views and outdoor
access for an outdoor therapy garden.]
This may be another option for veterans and others. He asked if there were any questions.
Chairman LoCastro asked about the recently opened Virginia Beach and Idaho facilities. Are they
occupied and do you have staff? If so, what’s the percentage? We’ve heard that of the nine facilities in
Florida, many aren’t fully staffed. He was the chief operating officer of Physicians Regional Medical
Center and it was hard to get staff. There’s a patient-to-staff ratio you must maintain, so if you don’t
have the staff, even if you have a waiting list of 500 veterans, you can’t bring them into a recently
opened facility. For the facilities that opened recently, how are you set up and are the homes suffering
due to staffing problems? Is it staff first and residents second?
Mr. Kolejka responded:
You must hire all your core employees before you can admit residents.
With veterans’ homes, there’s a minimum number of residents you need, and the VA will
come in with a survey team do a full survey assessment, which allows the state to ramp
up and complete the occupancy of the building.
In northern Idaho, at 64 beds, the total current capacity, they’re taking on four to six
residents each month. That’s their ramp up period, so you don’t have to hire all the
caregiver staff immediately. You can add caregivers as the resident population increases.
Because of the design of that facility and the evolution of the design, it’s easier to bring
on staff faster than we would with a facility designed under the previous Small House
design guidelines.
Our second veterans’ home, in Radcliff, Kentucky, which is adjacent to Fort Knox, has
been open since 2017, and it’s never been able to exceed 50% occupancy, yet they have a
roughly 300-veteran waiting list. The reason is that they can’t get the staff because they
don’t want to move there due to its relatively rural location.
What’s really hindering it is that it was a 12-bed household with kitchens in each and that
requires excessive staffing in each household, so they’ve never been able to open half the
building.
Chairman LoCastro asked if they didn’t realize there was a staffing challenge in rural Kentucky. Why
was it such a blindside, that you built such a beautiful facility that’s basically sitting half empty because
it’s nearly impossible to bring people there? Why build it there? Build it where the employees are is
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what we always say, even if veterans have to travel. Is that a lesson learned or were there people who
promised you that the staff would be there? What happened? We want to learn those lessons since we’re
in a very advantageous position here. We have hospitals that have challenges, as well, but we have some
other positives that other communities don’t.
Mr. Kolejka responded:
Part of it dealt with the fact that we were working under very rigorous Small House
design guidelines that were mandated by the VA that you could not exceed a certain
household size. You had to provide all of these dedicated amenities to each household, so
in some ways the designs were shackled to those Small House design guidelines.
However, in 2017 there was a change in VA rules, when the Secretary of Veteran Affairs,
Secretary Shulkin, allowed states to no longer be required to follow verbatim the Small-
House design guidelines and allowed them to either completely follow their own state
health department regulations or some type of a hybrid that allowed us as architects to be
able to have more flexibility and more freedom to design facilities that weren’t so staff
intensive.
We could develop them with shared dining venues that previously would never have been
allowed and allowing larger household sizes so we could provide for those.
There was some flexibility that allowed us to now do those things. We did require some
staff and, as a result, are now seeing higher occupancies, even in rural veterans’ homes
because of those changes.
Chairman LoCastro asked if those changes helped in Kentucky and if so, how is the Kentucky home
faring now? It’s almost a sin to have this beautiful facility and veterans in need, but staff doesn’t want to
travel to a rural area. What’s the prognosis in Kentucky now? What’s the occupancy?
Mr. Kolejka said it’s about 50% and it’s been operating for about six years. We’ve been talking with
Mark Bowman, executive director of the Kentucky Department of Veteran Affairs, about potentially
taking one of the household wings and making it into adult day healthcare or rehabilitation because
there’s a demand for that and the staffing ratios, particularly for adult day healthcare, are a fraction of
what they would be for skilled nursing, so that’s their hope. They are increasing pay and providing
incentives to get caregivers to move from Louisville to Radcliffe or to commute. There’s a commuter
subsidy that they’ve since put in place that’s helped to increase staffing, so they’re hoping to get to
about 75% occupied within the next year or two. They may look at repurposing the remaining 25% into
adult daycare or rehab.
Chairman LoCastro asked if that rural location was selected because they thought there was a large
number of veterans there, or was the land cheap and available? What was the reason for that location,
rather than build it in Lexington, where land is very expensive, and it could have had a different
outcome? What were the factors in selecting that location?
Mr. Kolejka said 125 acres was given for the project at no charge.
Chairman LoCastro said that makes sense. And the difference between Idaho’s 64 beds and Virginia
Beach’s 128 beds, was it basically land acreage that was available? Are the different sizes of the homes
based on what you think the population might be in the area and the footprint of the size you’d get?
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Mr. Kolejka said it’s a bit of both, but predominantly the size of a veteran’s home is based on the
veteran population in the area where you’re going to build the home. In the case of northern Idaho, there
isn’t a large enough veteran population to justify a home of 120-128 beds. However, we know the
population is continuing to grow. It’s also utilizing some of the population from nearby Washington
state, the Spokane metropolitan area, so we looked at trying to “right-size” the facility for this initial
development. However, as that population grows, we’ve designed the building so it can be expanded in
the future, maybe not to 128 beds, but maybe 90 beds or something similar. We try to provide that
flexibility. Because we could increase the household size, we could decrease the staffing required
compared to some of the former homes where we weren’t given the flexibility to do that. They anticipate
they’ll be about 90% occupied within the first 18 months.
Chairman LoCastro said he was stationed out of Hawaii and was surprised to hear Hawaii has two
homes and 180 beds, especially with the cost of land there. Obviously, there are a lot of active duty and
retired veterans there. Was the land there gifted or was there a sweet deal because it seems that would be
a high-dollar value. We have nine homes in Florida, but Florida is much larger than Hawaii and for
Hawaii to have 180 beds, there must be some reason, such as a waiting list of 1,000 people. At Kaiser
Permanente, the main hospital in Honolulu, they couldn’t throw enough money at the staff there to staff
that hospital, so they had a lot of traveling staff who would come in and enjoy Hawaii for six months
and get top dollar, but they couldn’t keep them. Tell us about Hawaii. We want to learn. We’ve made
some decisions here after hearing these kinds of stories. We don’t want the next veterans nursing home;
we want the best one. You’ve said how you would have changed the layout, size and structure. What
was special about Hawaii that got them two homes when land and staff are expensive?
Mr. Kolejka responded:
We’ve been working with Hawaii since 2014, helping them with their original grant
application for the Oahu Veteran Home in Kapolei, on the southwest side of Oahu.
Prior to that, Hawaii had one veteran home located in Hilo, a 60-bed home with an adult
day health program. Why they put it on Hilo, where the population of veterans is a
fraction of what it is on Oahu, was because, at the time, they couldn’t get any Oahu land
donated to the state, but they did on Hilo, so that’s where the first home went. It has
maintained an 80-85% occupancy level, but, unfortunately, had a bad outbreak of
COVID, which took the lives of many veterans.
Since then, land was transferred from the Hawaii Department of Residential Services, 7
acres given to the Office of Veteran Services to build a 120-bed home, so we were hired
in 2016 to design that home. Ideally, we’d love it to have been a single-story facility but
because we only had 7 acres, we couldn’t fit 120 beds, so we had to go to a two-story
configuration.
That home is currently under construction and is due to be completed next year.
Now Hawaii is shifting. They still have 53 beds allocated to them because they have a
fairly large veteran population, partly because of the large number of active military
bases on Hawaii.
But they want to build a 60-bed home, so they’re going to kick in the extra cost to round
up to 60 beds, so that’s the X-shaped design you saw earlier. That would then max out
their bed count and they will then be able to serve the vast majority of veterans who
primarily live on Oahu, Maui and the Big Island.
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There’s a small population in Kauai, but not large enough to justify a home of that size.
Chairman LoCastro asked if they did something unique with the two-story facility because we kicked
that around here, trying to figure out how we can maximize our footprint and the number of beds. On the
second story, did you make it all administrative because you worried about veterans going up and down
elevators? Do you have residents on both floors? Is it a mix? So that’s doable, but maybe not a
preference?
Mr. Kolejka responded:
It’s definitely not the preference to go with two stories because you have a bottleneck, an
elevator that residents have to come down. Particularly during the pandemic, that was a
concern because that’s a choke point where you have a potential for infection-control
issues.
What we did in Hawaii is similar to Virginia, 15-bed households stacked on top of each
other so they each had dining and living spaces, a lanai or large balcony with outdoor
garden spaces.
The community center was compressed and extruded into a second floor, allowing for the
pharmacy and therapy to be on the upper floor, with the rest of the functions, like the
kitchen, laundry and administrative on the ground floor. It was because we were limited
to 7 acres.
For 120 beds, we’ve built them in such a way that they can be done on 12-14 acres, but 7
acres is too small to be able to get a single-story layout.
Commissioner Saunders said the presentation was helpful and asked to focus on the north Las
Vegas facility and the Collier County site, 11.7 acres of buildable space with water management
to be handled off-site. The Las Vegas home that’s going to be completed in 2026 seems to have a
really efficient design. One of the visions that all of us have had is that you’d have the 120 beds
on the first floor because that’s ideal, and the ancillary services, such as adult day health care,
rehabilitative services, and other services, would be on the second floor because then you don’t
have to worry about the bottleneck at the elevator with residents. Is that something that makes
sense, and would 11.7 acres fit the bill, recognizing that it’s all buildable space?
Mr. Kolejka said the North Las Vegas home is situated on about 12 acres, so it’s conceivable
that the tic-tac-toe layout could work on something that size. The only time we’ve ever done
another with a second story was our 120-bed Tucson home, which was built on 8 acres and very
tight, so we had to go with two stories at the community center and on that floor we had the
pharmacy, administration and other ancillary functions, and then all the resident-focused areas,
like the barber shop, library, breakroom, bistro, coffee shop, were all on the ground floor. So yes,
you could take some of those non-resident-facing spaces and put them upstairs and pull in the
wings to consolidate that and provide a smaller footprint, which ultimately is great for residents
and staff because they don’t have to travel as far.
Commissioner Saunders noted that the VA accepted that design and asked if we added a
second floor for other ancillary services, would there be a problem with the VA and the federal
government providing funding, as long as the 35% local match is provided? Would there be an
ability to get funding for a larger facility with a second floor that provides adult daycare services,
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rehabilitative services and others for non-resident veterans? Is it doable at the federal level?
Mr. Kolejka responded:
Adult day healthcare is an interesting situation because under current rules, which the VA
is considering modifying, the VA will provide 65% of the typical per diem that they
would offer for inpatient skilled nursing care for every veteran who participates in adult
day care, as long as they come at least three days a week, six hours a day for no less than
18 hours a week.
However, the VA currently does not provide any construction funding for any newly built
adult-day healthcare.
They will only fund construction if it’s a renovation of an existing component of an
existing state veterans’ home.
What most states, such as Boise, Idaho, are doing is they’re providing an under-designed
project and now they can construct that component of the veteran’s home at a 100% cost
to the state, but they would then be able to realize all the per diem for the participants
who are part of that.
Although you may build an adult-day healthcare program designed for 40-50 participants
at a time, realistically you probably will have 150-200 participants in the general area
who are part of that program that you can realize that per diem because they’re not all
coming daily. You may have one group Mondays, Wednesdays and Fridays and another
group Tuesdays, Thursdays, and Saturdays, etc.
The VA will not contribute to the construction cost of a new veteran’s home, unless you
establish a veteran adult day program. This only applies to an existing home. If you can
admit three participants, you can convert part of a wing or conference room and renovate
it for adult day care, and now you have an existing program. At that point they will pay
65% of the construction cost of a new adult day healthcare, provided it’s on the same site.
Commissioner Saunders responded:
That works well, so we could theoretically do the Las Vegas type home, which takes a
smaller footprint, and 11.7 acres would probably work with that and on a second floor,
the federal government could pay for some ancillary services that are not day healthcare
services, but the portion of that construction that’s the adult daycare would be a 100%
local match?
Whatever that delta would be between the cost with and without that would be borne by
the state. These are the questions we want to address.
Our vision is to build a model veterans home for the country. The Las Vegas model is
ideal because it’s much more efficient to operate and it would be easy to go to the second
floor for other important services.
We have a community here that is very philanthropic and we’re going to be able to raise
funds to assist all that we’re trying to do, but we also have people who will volunteer. We
have senior centers all over the county with tremendous volunteers who provide a lot of
those services, retirees who are qualified to provide daycare-type services, but we also
have a couple of hospital systems that are very philanthropic.
We can staff these facilities, but he understands there have been problems in other parts
of the country and we’ll have some problems here, but not to that extent.
We may be able to increase our 11.7 acres a bit, but that’s the site we know we have. If
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we can fit that Las Vegas-type of facility and work with the Florida Department of
Veterans Affairs on that, with services on the second floor, that would be ideal.
He knows Mike isn’t officially onboard, but some funds will be available after July 1st for
some preliminary architectural and design work. When can Mike or someone from his
team look at our site?
John Mullins, who has been integral to working on the details, has all the information
about the site and can provide it.
When can we jumpstart the evaluation of the site from an architectural standpoint to
make sure that 11.7 acres and this location will work?
Mr. Kolejka said he’d have to defer to Bob.
Commissioner Saunders said he expected that and thanked him for the information. The Las Vegas site
plan looks like a nice, efficient facility that will fit nicely here.
Commissioner Hall noted that some of his questions were answered. He asked what we can learn about
why staffing is short. Are there pay guidelines, standards or pay scales that have to be adhered to? Or is
it for the market to determine? Are you finding staff shortages because of the skill level in certain areas?
What can we learn from that?
Mr. Kolejka responded:
Bob can speak about pay levels.
When it comes to our national experience and where we’ve seen veterans’ homes
struggle, the ones that are struggling the most in terms of occupancy, despite a large
veteran demand, are typically in rural areas because it’s harder to attract staff there.
Some states have found an interesting way of addressing that by contracting the operation
of their home to a third party.
In Utah, all four of the veteran homes, including the new one we’re now designing, are
operated by a third-party group, Avalon. There are several companies. Our Houston
veteran home is run by Touchstone, the Hawaii homes are run by Avalon and others, and
HMR operates many in the southeast.
They have a different pay structure than what a state may have, but that varies by state.
Some states operate their homes and others subcontract that out to a third party.
In larger urban areas, such as Collier County and Naples, it’s easier to attract staff than
more rural places like Radcliffe, Kentucky.
Commissioner Hall said it’s hard to imagine people not flocking to Big Spring, Texas.
Mr. Kolejka said Big Spring is one where we helped with renovations. Their occupancy is roughly less
than half what the capacity of the facility is.
Commissioner Kowal noted that Virginia Beach and Virginia are similar to Florida, with a large
veteran population, and that 128-bed facility was completed in 2022. How is it doing and where is it at
with staffing?
Mr. Kolejka said it admitted its first resident in February after a ramp-up for staffing. They first had to
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complete some Virginia Health Department surveys, so that took time, but they opened on February 10th
with three veterans, and they’ve been adding six to eight veterans per month. They anticipate being at
full or close to full occupancy within about 12 months, in February 2024, but believe they may beat that.
That’s partly because Virginia Beach is a large municipality and doesn’t have the same staffing
challenges as Radcliffe and other more rural locations.
Commissioner Kowal noted that many young veterans here travel to Tampa for surgery, such as knee
replacement, and we just finished our longest war and many people served for many years. Could the
second story be occupied by a physical therapy facility? Are they allowed to use outpatient services,
such as physical therapy treatment areas? Would that be available? They have a hard time getting
follow-up treatment here after traveling to Tampa. It’s kind of a barren area here.
Mr. Kolejka responded:
The VA requirement is that they’re only providing per diem for inpatient physical
therapy and that can include a short-term stay under 90 days, but they’re working to
change that to allow for outpatient care.
We’re designing all our therapy spaces in our homes to allow for outside dedicated access
and other things we’d like to add in the future, but only inpatient therapy is permitted
now under the current VA per diem for state veterans homes.
The National Association of State Veterans Homes is lobbying hard to try to change that
so we can have outpatient care. That’s where the adult day healthcare program comes in,
as a way to not so much get around that, but to help mitigate that, because you could offer
therapy as part of adult day healthcare.
If you have a group of veterans who don’t need to be in a skilled nursing facility but need
therapy services, you can add adult day healthcare and leverage staffing between the
home and adult day care, so you’re getting the most bang for the buck in terms of both
per diem, income to the state, and minimizing the number of additional staffing.
Adult day healthcare would be the way to potentially address outpatient therapy, while
inpatient care would be done for residents who live there.
Mr. Aszatalos said Commissioner Kowal is right. Veterans who need rehab services must drive to
Tampa or across Alligator Alley now, so this would fill a hole if we were able to do outpatient therapy.
But this nursing home is really going to be built for the post-Vietnam and post-911 veterans. If you look
at the time frame, by the time we get this built, there won’t be any World War II or Korean War veterans
here. There will be some Vietnam War veterans, but we’re really building it for post-Vietnam veterans
who have amputations, prosthetics and need rehab and wound care, so even inpatient-wise, we have to
look at services for them, too.
2.B. Stephanie Wallace, senior vice president of programs for Easter Seals Florida, and Jill
Gentry, vice president of programs, will discuss Easter Seals’ experience operating adult day cares
in Florida and contracting with the USDVA for adult day health care services.
Ms. Wallace told the BCC:
Easter Seals Florida is part of a larger national network and Easter Seals Florida has 40 of
the 67 counties in Florida as our territory.
We offer services statewide that span the lifespan, providing services for individuals and
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their families and those disabilities.
We offer early intervention, child development centers, workforce development, short
skills training with certifications, life skills, adult day training and adult day healthcare.
Veterans hold a special place in her heart because her husband was an Army combat
engineer; she was a military spouse for many years; her daughter is a Navy veteran, an
astrophysicist who did great things with her GI Bill; and her son is an active-duty Marine
stationed at Camp Pendleton. Jill also has connections to veterans.
Jill Gentry, our VP of programs, oversees our two adult daycare and healthcare centers,
in Winter Park and Gainesville. She’ll share information that’s pertinent to a lot of things
we’ve heard today, and she’ll be happy to answer your questions.
Ms. Gentry told the BCC:
Sometimes the biggest question about adult day healthcare is why would someone bring
their loved one or choose to come to an adult day healthcare facility? It’s the desire to
stay in your home and do it safely. That’s always the best option, but there are times
when loved ones need more support than the caregiver can provide, so adult day
healthcare fits a good part of what’s needed.
Adult day healthcare is a secure, safe environment for someone to spend the day with us
and receive medical support, social interaction, help with any cognitive decline and
simple tasks. It fills an important role and keeps someone in the least-restrictive
environment as long as possible.
It can be a nice bridge for someone who eventually will be in a residence. It provides a
caretaker with an opportunity to prepare for the loved one to not be in their life on a daily
basis in their home and allows a veteran to build camaraderie with others outside their
spouse or adult child, who has been playing the role of a caregiver.
As you’re looking at blending a structure with both a residence and adult day healthcare,
there’s a natural flow for where that could build, as well as eliminate, some potentially
trauma-based interaction with someone who is now leaving their home for the first time
after they’ve been with a caretaker, their sole support. It will make the transition a lot
easier.
The best we can do is support someone in a time of transition.
Her husband was in the Army for 17 years and he misses it terribly. Nothing has ever
compared to his military career. Her stepson also was an Army medic at the time he died,
so veterans are extremely important to us, and we enjoy our time with them, personally
and professionally.
[She presented a slideshow of Easter Seals’ clients to show the BCC what their properties
and clients look like, and the joy and energy Easter Seals gets from working with them.]
From 2018 to 2022, our two adult day healthcare centers served over 200 veterans.
Younger veterans were the smaller percentage served; veterans under 60 were only
served at 1%; from age 61-70, that jumps to 12%; from 71-80, it jumps to 27%; and from
80- 90, that jumps to 34%.
What’s impressive is that over 25% of our veterans were in their 90s. What a gift to be 90
and to have someone in your life who is your caregiver, who cares enough and advocates
enough to get you to services and supports you, but also ensures you’re still in your
home.
We’ve learned so much from these individuals. There’s a richness in that.
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It’s very forward-thinking to be considering the veterans you will be serving once the
building is constructed. It’s a sad idea that we are losing our veterans, so we appreciate
the time that we have with them.
In terms of Easter Seals’ involvement with the VA, Easter Seals national has been
serving veterans and their families, whether it’s through education or training or just in
general wellness through health and emotional support, since World War II.
Easter Seals Florida has been serving veterans for over 20 years and we work with two
ADHCs (Adult Day Healthcare). One is Winter Park, a program called Daybreak, and the
other is in Gainesville, Altrusa House. Both work with the local medical center, and
Orlando VA Medical Center is our primary support. We also work with the Malcolm
Randall Medical Center and Lake City Medical Center.
We receive veteran referrals. Self-referral is often something that we see, but the vast
majority are veteran referrals from the VA and the social work teams at the VA are
essential in that process. Whenever we receive a referral, the veterans and caregivers are
invited to our facilities and given a comprehensive tour. The veterans see other veterans,
our spaces and staff. It’s full transparency.
We want that initial agreement to participate to be done in confidence, and to alleviate
some of the stressors for the caregiver, who may be feeling a bit guilty about asking for
help.
She’s often asked if she’d put her parents in this program. The answer should always be
yes. Sue Ventura, our CEO, had a father she loved dearly, and he was a veteran who
started having cognitive decline and she tried to be his caretaker. She realized very
quickly that it wasn’t something she could do on her own, so her father participated in the
Winter Park Daybreak program. She said that’s exactly what her father and she needed,
so we really do believe in our services and are willing to put our loved ones in our
services.
The relationship of a veteran and caregiver is important. If it’s your spouse or adult child,
that’s a big shift in dynamics, so we try our best to serve the caretaker as much as the
veteran. We’re building as much normalcy back into that relationship as possible while
the veteran remains in their home.
During admission, we do a series of intakes and surveys to understand what the veteran’s
level of social determinants of health are. Are they positive, are they fractioned, what can
we do to build upon those strengths? We do that both with the client and caretaker. With
the caretaker and client, we revisit that in six months to see what impact we’ve made, but
we also use that data to understand what modifications we might need to make within our
centers.
We’ve learned interesting data that aligns with what we believe we knew about our
community, but further supports and drives decision making.
In North Florida, where we have two centers, these are extremely different communities.
When we do caregiver surveys, what we’ve learned has illustrated some of these key
differences. We asked caregivers what does your loved one coming to our ADHC mean
to you, what does it allow you to do that you previously could not do? In Gainesville,
70% said it allowed them to either re-enter the workforce or stay in the workforce. That’s
almost the exact opposite of the response in Winter Park, where they say they can now
make their appointments, take care of themselves, have social connections, do more for
themselves and their well-being.
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What that does is it drives some of our decision making around hours of operation. It tells
us that if we have 70% of our workforce in Gainesville dropping their clients off to us
and the caregiver is going to work as well, then we need to be sure to open a bit earlier or
stay open a little later. Those are the modifications we’ll make. They don’t seem like a
big deal, but they’re incredibly important to someone who’s trying to stay in the
workforce and keep their loved ones safe.
Transportation is not something we do in-house. We rely on and work with local
transportation companies. Yours is CAT. We have Lynx, so we’ve become well-versed in
coordinating and helping families secure and set up the transportation they’re going to
need.
Caregivers in Winter Park rely on public transportation, while caregivers in Gainesville
are picking up and dropping off veterans, so those nuances of the impact to caregivers
add up and tell us something about how we can change, modify or maintain the
operational decisions that we make.
Caregivers are the ones who have our clients in the evenings and weekends, so
communication lines are extremely important. We often observe things a family member
doesn’t see, and sometimes family members tell us something that happened on Sunday
that we really need to know on Monday, so our nurse and center director are very active
participants in those conversations. Both ensure there are no missed moments for
improvement or clients’ protection and safety.
For outpatient therapies, we coordinate with outside entities that want to come in and do
OT, PT and speech therapy as much as we can, so that’s one less stressor for the family
and one less appointment a client needs to attend to elsewhere.
We follow all AHCA (Florida Agency for Health Care Administration) regulations,
which are very clear and ensure you have a safe and secure environment for your client,
whether it’s the qualifications of employees, ratios, or the number of rooms you need. We
always try to go beyond what’s required.
When we look at ratios, we always hold out key positions from ratios, so we’re
concurrent planning and on a day when staff are out, we have more staff than we could
need. Size can make or break you, whether it’s their temperament or their demeanor.
We’re showing up and being consistently on time. These things will make or break a
facility, so we’re happy with the teams we’ve developed.
We’re also very careful to never understaff and to always be concurrent planning so
we’re always within the ratio.
What helped push morale for our staff is we’ve invested in our staff who don’t have
certifications. Most staff are required to have certifications. You have to have an LP, a
consulting RN and CNAs. You have to have degree positions, but we also have
caregivers who are not family members. These are professional caregivers who are
essential to the daily dynamic of our clients. We put them through caregiver training to
get them certified. We wanted every person in our building to have some level of a
professional credential. It was one of the most successful things we’ve invested in and
we’re just seeing the end result of those efforts. We had health staff go through that
training last year and it will be something we continue. Those opportunities for
professional development will continue to add to our stable workforce and potentially
will be a good recruiting tool.
We have standalone ADHCs, so our buildings look different from what you just saw.
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When people first visit us, we’re not a clinical model, so that home feeling, the non-
clinical feel, is important and diffuses a lot of concern. It becomes a real comfort place to
come to daily.
Because you’re building a new facility and are looking to go in potentially with a
cohesive model of an ADHC and residential, some of these would not be as applicable,
but food service is important. We are not currently providing food that we cook. We’re
working through catering services at both our locations through the national food
program.
Part of design considerations are safety issues. There will be a comprehensive emergency
management plan that will be required for an adult day healthcare center. We act
according to all the regulations in those areas. This last year, we also added an active
shooter plan. We initiated efforts on that three years ago, coordinated with local law
enforcement and are registered. Our blueprint is with the sheriff’s office.
Both our ADHCs have extensive outdoor space. It’s incredibly important to clients. It’s
not only where you have some normalcy or where you do barbecues, outdoor activities,
shuffleboard, etc., it’s also where clients get autonomy. Our veterans really deserve that.
It’s an interesting dynamic when you’re creating a place of safety for a client, while
trying to make sure they feel autonomy and are empowered. It’s a fine balance to
achieve. Our outdoor space permits our veterans with an opportunity to step outside when
they want to spend time outside with friends, doing whatever activity they like to do.
We keep records of inclement weather and have cooling stations. It’s still structured, but
it feels very empowered and very choice based.
An ADHC’s planned social activities are invaluable to the overall well-being of a
veteran. We will celebrate anything and if you want to know if there’s something to
celebrate every week, there is. We are very focused on the normalcy of bringing
caregivers in and having opportunities to enjoy and share camaraderie, not only with
people at the center but with their loved ones and family members.
Our activities are always driven by an agenda, and they’re also very engaged with
community partners, such as UCF, UF and Rollins College. All these big players come in
and are very important for some of the activities that we do.
We do a big push throughout the year for activities that involve exercises that keep
people moving and fluid. We track progress, so people who are struggling or losing
mobility are pushed in proper ways to maintain what mobility they do have.
We engage with our local ROTC and local valor clubs to engage our clients and prevent
cognitive decline.
At the core of our activities are music and art. There’s a wealth of evidence that supports
the importance of music and art for people in the aging process. Our music programs
include drum circles, local bands, pianos, karaoke, etc. We also have music playing at
some point in every facility and we do guided exercises like Alzheimer’s poetry projects,
opening minds through art, and Memories in the Making. It’s all about guiding them
through a process to help them draw the memory and create either an art or poetry item
from what they retain, recall and feel comfortable sharing.
We also offer a verbal veterans history project aligned with the Library of Congress. We
follow their guidelines and capture the verbal history of our veterans. When that’s done,
it’s reported to the Library of Congress, so we not only want to honor veterans when
they’re with us and receiving our services, we want them to know they’ll be remembered.
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Chairman LoCastro said as we get closer to design and all the steps that lead up to the ribbon cutting,
we’re going to pull from all those things you mentioned so we know we have the best facility. You have
some proven things that you’re sharing with us, so we’re not going to forget the proven winners. We
want to add that to our home, as well, so thank you.
2.C. Kurt Micheels, construction projects quality manager, Department of Management Services
(DMS), will outline the DMS policies for moving forward with construction of a Florida state
veterans’ nursing home. (via Zoom)
Mr. Micheels told the BCC:
The main thing to consider is that the overall project budget is going to exceed $4
million, and we don’t know what the total budget is going to be and state statutes
mandate that we have to advertise for the architect and construction manager.
At the beginning of this project, right now we’re waiting for $500,000 for site evaluation.
That money has passed through the legislature and we’re waiting for approval, probably
sometime in late summer.
Then we need to advertise for the architect, who will do the site evaluation part of it,
which involves the Level 1 and Level 2 surveys.
[Commissioner Kowal left the meeting at 4:33 p.m.]
Some environmental surveys have already been done on this site, so part of that work will
be to take the existing surveys and see what remains to be done.
We’ll need to contact the Southwest Florida Water Management District and talk to them
about what we need to deal with, and the Building Department because all state facilities
have to be approved through the local authority with jurisdiction.
The end result of the site analysis would be a report. There’s criteria set by the FDVA
(Florida Department of Veterans’ Affairs). Then there would be a series of drawings, site
plans that show a hypothetical design.
He was the state’s manager for the Ardie R. Copas (State Veterans’ Nursing Home in
Port St. Lucie) project that we just built. We were thinking of using that as a baseline, but
there’s some latitude on how we proceed, given the variations on how this design might
be configured to fit the site.
What we’re looking at is if we get those funds in late summer, advertising usually takes
about three months, the architect will be selected and then it will probably take us into
spring to complete the site-evaluation process.
Our deadline for the VA application is around April 2024, so in a perfect world, in the
beginning of 2025, we would get VA approval and the additional funds. Then we’d be
able to get our same architect reactivated to commence design, the schematic design,
design development and construction documents.
From that point, you’re looking at about one year of design and about another 1½ years
of construction, not taking into account things that can happen, like COVID.
That’s how you’d proceed to put the project together and where we are now.
Chairman LoCastro asked if he understood correctly that in a perfect world, next spring the site
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evaluation would possibly be completed, 2025 would be the final VA approvals of the design,
and then it takes about a year to design, so all of 2026 is eaten up with the next steps of design
and construction. Then you’re in 2027 or 2028 for a ribbon cutting. Is that a good guesstimate
with what we know today?
Mr. Micheels said that’s correct.
2.D. Bob Asztalos, deputy executive director, Florida Department of Veterans’ Affairs, will address
next steps in the process, including budget development and funding timelines. (via Zoom)
Mr. Aszatalos told the BCC:
The Florida Department of Veterans Affairs opened its first home in 1990. We operate 10
state veteran nursing homes and one domiciliary, an assisted-living facility.
You’re really going to build the nursing home for the next generation of veterans.
The two homes we’re in the process of opening now have Korean and World War II
veterans and you’re going to build for the next generation. He admires that you’re thinking
forward on that, as far as expanding the services we offer.
Someone asked why there are so many beds. All our homes have 120 beds. That’s
because, under Commissioner Saunders’ leadership as a state senator, they wrote the rules
for nursing homes in the early 2000s. What they did was the most efficient operating
nursing home under all the rules, 120 beds with three 40-bed units. That staffs the most.
Every time you deviate from three 40-bed units for a 120-bed nursing home, you add
additional inefficiencies and staff, etc.
That was a regulatory model built in the early 2000s, and that was fine for the World War
II generation, with two, three or four people in a room with cinder block buildings, but it’s
a new world now.
We want to accommodate people by making the nursing home less of a medical model
and more like a hotel. As Mike said, the VA took the Small Home concept to an extreme
but now the pendulum has moved to the center, where you want homes to have small
communities, not three 40-bed units.
That’s why staffing becomes more difficult, and we need to find efficiencies.
As Mike said, those efficiencies are important. What attracts staff is putting a nursing
home in a building with neighborhoods, bus routes and transportation.
When you look at nursing home staff for 120 beds, you probably have 120 staff, mostly
low-wage workers who work in dietary, housekeeping, and as CNAs. They’re paid $15-
$17 an hour, so we have to make sure it’s in an area where there are neighborhoods where
folks can live and have transportation.
Those are biggest factors driving staff into veterans’ homes.
As Kurt Micheels said, there’s a $500,000 allocation in the budget. We’re hoping the
governor signs that, and we can get to work on it because we have a timeline we have to
follow and have to align funding from the County Commission, which taxpayers in your
community generously put up for this home.
The state, federal government and everybody has their own rules and timelines, but
between now and April 15, 2024, we’re going to have to submit our request for the home,
so we’re going to have to figure out what exactly we want to build, what services we want,
where we’re going to put it and can we build it on that property? We have to put that all
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together and submit it to the VA.
We’re also going to have to make a decision because currently we have a construction
grant request that’s sitting high on the VA priority list. That construction grant is for a
112-bed facility that the VA would give us $42.5 million for, with a total price tag of
$65.4 million, which we could probably modify up to $72 million.
We’ll have to make a decision. Can we build the facility that we want and provide all the
services we want within the framework of this existing construction grant that’s already
high up on the VA priority list? If we decide we can’t do that, then we’ll have to create a
new grant and take that to the VA by April 15, 2024.
Between the county providing the 35%, which the state would have to put in an escrow
account, and the April 15, 2024, deadline, we could start moving ahead.
There are numerous steps. We’d have to submit that to the VA, which would have to put
that on its funding list for the 2025-26 year. If Congress appropriates the money and has
enough to fund it, then we could start moving and then we could follow Kurt’s guidelines.
There’s a lot of work and decisions that must be done in the very near future.
He’s excited to see the presentations and what other states are doing because they’re doing
exactly what you all want to do and what we all want to do. The most important thing for
the veteran population that we want to take care of is that we can now provide them with
options.
The only option we could provide a veteran now is long-term debt, but if we told them
they could stay in their home and we could provide them with adult daycare or
rehabilitation services and keep them in their home until they need to be in the home, then
you really need a heavy rehab component to this home, so we’re really taking care of the
needs of the post-Vietnam veteran generation.
We need to work that out between now and April 15, 2024.
We’re excited to be partners with you, the Commissioner’s, and residents of Collier
County to make this a reality.
Chairman LoCastro told the presenters:
This has been very beneficial for us. He took notes here and while in Tallahassee. We
have so many advantages here in Collier County that maybe some other communities
don’t. We have the land, the money already committed and the surrounding community.
We’re not out in the boondocks, although, as we discussed in Tallahassee, staffing is a
challenge for everyone.
We have so many colleges here, FSW, FGCU and others, that specialize in medical
courses, and we work really hard to entice graduates to stay here.
In his past life as the CEO of Physicians Regional Medical Center in East Naples, we
pulled from many of those colleges. That’s not to say that staffing is all college graduates.
We’re trying to get experienced people, but you need a mix, and we have feeder
transportation.
We’re trying to make these homes more like hotels, more comfortable, not like a hospital.
In my district, the JW Marriott, the biggest company as far as hiring on Marco Island, we
have the ability to make adjustments that are needed because Collier County has such a
robust bus service. We roll a bus out in the early morning hours, and it’s totally packed
with workers for the JW Marriott and it pulls up in front of the hotel at the exact time the
general manager asked us to pull it up in front of the hotel. We do that in many places
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countywide, so once we figure out where our veterans home workforce is coming from,
we can make those changes in transportation to take advantage of it.
We have the appetite here. We don’t want the next home; we want the best home. It’s
more than a nursing home, it’s providing all those other services.
We’re committed. Collier County has not only a large veteran population and many who
don’t need that home, but as Commissioner Saunders said, a very robust philanthropic
community and some who are veterans and some who are super patriotic people, so we’re
counting on the big supporters of this idea to step forward now that it’s become a reality.
We’re going to shake those trees so we can round out the home and make sure we can
maximize it to build a home for the next generation of veterans.
This will be the benchmark, a model home. We’re going to steal great ideas from what
Mike presented. We want your starting point to be the Collier County home and we hope
people move forward and improve it from there. We’re off to a great start.
Commissioner Saunders thanked all the presenters and said:
This was very helpful information.
You have an existing application that could be raised to $72 million. Our $30 million plus
interest will be over the 35% required if we’re at that number.
Are you able to do something with the $65 million application to increase those numbers?
You said maybe it can be increased to $72 million, so can it be increased a bit more to
accommodate a larger structure that’s more modern? Can you amend the application to
save some time?
Mr. Aszatalos said yes, it will save time and will move faster if we could use the existing application.
The VA allows a 10% add-on to it and that’s why we could raise it from %65 million to $72 million.
Chairman LoCastro said we’ll take it.
Mr. Aszatalos said we want to design this, and we have to ask if the $72 million price tag works.
You’re right, there are excess funds that Collier County collected in addition to the 35%, so the question
is, as Mike pointed out, the VA may require that the adult daycare portion, if we’re going to take that
route, has to be funded 100% through state funds. The question we’d have to answer is, do we want to
use state funds and let’s put in an adult daycare, as opposed to creating and building a conference room
for three people and then add it on later. That would be one of the questions if we use those excess
funds. The other thing is outpatient therapy. He heard Mike say they’re not funding outpatient therapy,
so would we have to do our own construction there for outpatient therapy?
Mr. Kolejka said unless you do it through the adult day healthcare program. If you do therapy that way,
then technically it’s outpatient, so you’d have inpatient therapy as part of the veterans’ home and then
outpatient care would be lumped in with the adult day program.
Mr. Aszatalos said what we’d have to do is defend and lay out the list of other services we want in this
building, in addition to all your services. We’d have to see what the VA will fund and what are the
additional services that we would put in the building that they would not fund, but they would allow us
to fund and look at our budget and then go from there.
May 25, 2023
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Commissioner Saunders noted that the North Las Vegas model on about 12 acres is different from the
Small Home design we see around the state and appears to be a relatively new type of design. Is it
possible for us to look at the Las Vegas design? Would it be approved by the state and federal agencies?
Mr. Kolejka said it’s already approved for Nevada by the federal government.
Commissioner Saunders said so if it’s going to be approved by the federal VA, could this be approved
by the Florida Department of Veterans Affairs?
Mr. Aszatalos said he’s excited about the scope of services, but Kurt would know more about the
construction side because he built our Ardie R. Copas home and completely renovated our home in
Orlando.
Commissioner Saunders noted that the Las Vegas model is different from the homes in Florida. Could
it be a model in Collier County?
Mr. Micheels said the Ardie R. Copas plan was designed to VA requirements, but we had some
budgetary difficulties and then word came out that we didn’t have to literally adhere to the VA
requirements and could make some changes, so Ardie R. Copas is a hybrid design that takes into
account these things. It’s very similar to some of the things Mike has shown, so we have a lot of latitude.
You could possibly do something closer to the VA CLC (Community Living Center) greenhouse design,
where we could go through a hybrid. AHCA likely would approve it, as long as we meet the spirit of
59A-4, or whatever has become the guidelines, but it’s definitely doable.
Commissioner Saunders said assuming that the Las Vegas model will fit on our 11.7 acres, plus
possibly a bit more, and we want to go up on the second floor for the adult day healthcare, there would
have to be a splitting of what the cost would be for the main building/nursing home portion and then
perhaps different funding for adult daycare. Is it possible to split out all those costs so we could utilize
the $72 million from the federal government, which would include our 35% and whatever we have left
over or additional money, if necessary, to add on to it. Is that possible?
Mr. Kolejka said you would have to split it out by VA requirements, so you would have two grants.
You could use the existing grant to fund the veteran’s home and you would then have a separate
application for the adult day healthcare in which the construction cost would have to be 100% borne by
the state of Florida. Then that would give you a separate application that would be inspected once it’s
done and you’ll be eligible for the per diem for that minimum of 18 hours a week per participant at the
65% rate of the in-patients’ per diem.
Commissioner Saunders said at today’s market or the market you may see in a few years, can you
build the Las Vegas home for 72 million?
Mr. Kolejka said we recently priced our 105-bed Salt Lake project, which is a bit smaller, and the
construction cost is currently coming in at about $52 million and the total cost, including ancillary costs,
for Salt Lake is about $64 million.
Commissioner Saunders asked, so $72 million-plus could get that portion of the deal done?
May 25, 2023
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Mr. Kolejka said it’s conceivable. That’s in today’s dollars.
Commissioner Saunders said they appreciate everything the state is doing and Kurt’s flexibility in
terms of looking at this because it is different from what you had done, but this could be the answer for
Collier County in the sense that it definitely would fit on our site. It’s more efficient to operate, meets
the needs of the veterans who would be residents there and gives us the opportunity to go up on the
second floor to provide other services, so he’s optimistic we can move forward with it. He thanked them
all for this information.
Chairman LoCastro said our concern will always be the funds. We’re in the middle of designing a
behavioral-health facility in Collier County and it doesn’t have a five-year timeline, but we already
found that what $25 million would have built 10 months ago won’t build the same facility now. A lot
can happen in five years. Hopefully, we won’t have hurricanes or storms that will increase the cost of
materials and construction teams. We’re in a tough spot now where we’re looking at our behavioral-
health facility and having to make some difficult decisions on whether to make it smaller, tighter,
different or build in different phases. It would be disappointing if there were major differences in costs
five years from now. We’re going to charge forward, but it’s obviously something we want to continue
to keep on the short list and look at how far the dollars will go.
Commissioner McDaniel noted that the application is high on the priority list for the VA, along with
the timing that comes with it. Is it possible to use the application that’s high up on the VA priority list
and phase the project so we have enough available money to have 50 beds? He noticed that a few
projects were phased to be set up for future expansion. Would it be possible to utilize the application we
have in place, move forward with those revenues and phase the project to start off with 60 beds and the
magic number is 120 beds, then do a separate application in 2024, 2026 or whenever for the balance of
that construction? Can that be part of the discussion?
Mr. Kolejka said the VA provides some flexibility to adjust the bed count up or down. Historically,
we’ve been able to adjust that number by about 10%, either positive or negative. There are other
elements that can come to bear. For example, we’ve had a couple of projects like the second Kentucky
home we’re doing in Bowling Green, which looks a bit like the Post Falls, Idaho, project. We reduced
the number of beds from 90 to 60 beds because we realized that the construction costs could not support
that because they put the application in almost 10 years ago, so the VA allowed us to reduce that while
still maintaining our spot on the priority list. That’s an example of where we were able to reduce it by
more than 10%. Historically, we’ve gone up or down about 10%, so you can change the number of beds
and not lose your spot on the VA list.
Commissioner McDaniel noted that we’re already in the process with an application that’s fairly high
up on the priority level for approval, but he doesn’t know if we can do 120 beds for $72 million and
10%, plus extra money. Can we explore the opportunity of seizing the opportunity or the advantage of
having an application that’s already high up on the priority list to be able to take advantage of that and
not lose the time, have to reapply and go back through again. Is that plausible with the state process?
Mr. Aszatalos said as Mike said, it’s a 112-bed application and you could swing that 10% either way.
We have to think that through because you also want to factor in the need for the home and the veteran
May 25, 2023
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population. Collier County has a high need for a nursing home, a lot of veterans who will need to be in
beds. When he looks at the need study, he doesn’t see an issue with finding veterans to fill a 120-bed
nursing home, so what would be the justification for telling the VA there’s a high need for a nursing
home, a community that needs 120 beds, but we’re going to build a 60-bed nursing home? We have to
think that through. There may be a 10% adjustment either way, but you need to think that through a lot
more if you want to shift beyond that modification.
Commissioner McDaniel said he wasn’t suggesting scaling it back from 120 to 60. He was suggesting
they build the 60 beds with the available funds that we have in an application already in the system and
high up on the priority list and if we had to do another application for the adult daycare and the second
phase, that’s the approach he was taking. He’s not suggesting scaling down to 60 beds. The question is
once we come up with the design, is it phase-able to accomplish that? He’s seen the needs analysis and
agrees the community can support a 120-bed facility.
Mr. Aszatalos said he’ll review that with his team to give him a better answer.
Commissioner Saunders said it sounds like there’s enough money in this application to do the 120-
beds and go up or down 10%, that we don’t have to worry about trying to phase this. It’s obviously
going to be a lot cheaper to build in one phase than phasing it, so that’s something that may be worth
looking at, but that’s not where we’re going to be.
Commissioner McDaniel said it depends on the design.
Chairman LoCastro said the state controls timing and doesn’t want to get ahead of themselves and
build too many homes that sit empty because of staffing and occupancy. But if, as Commissioner
Saunders says, there’s something that seems like it might fit, a previous building that has been built, or
something that’s currently being designed, we don’t need to redesign the wheel, but does that speed up
the timeline a bit if there are some blueprints for a current facility? He assumes they look those
blueprints and note that there are some great things there, rather than just starting from scratch. Does
that tighten the timeline if some of these other facilities have a similar footprint to us? Obviously, we’re
always looking to make improvements, but does that tighten anything or is it not negligible? What
stretches the timeline isn’t funds, but staffing. Can the architects steal from other designs to tighten the
timeline?
Mr. Aszatalos said the biggest factor in the timeline is the U.S. Department of Veterans Affairs, the
biggest shareholder, because they’re going to own 65% of the building and they have a very lengthy
process. Yes, it’s very helpful to use things that they have seen before. That’s the real benefit of Mike’s
presentation. Mike showed us what the U.S. Department of Veterans Affairs has already looked at in
other states and approved, and that will help our application go a long way in that process. If we added a
service that no other state Department of Veterans Affairs has put in there, that would take more time by
the U.S. VA.
3. Public Comments
Eldon Solomon told the BCC:
He’s the CEO and director of The Journey Home.
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He introduced Jacqualene Keay, the veteran outreach team site director.
The Journey Home is a national veteran outreach organization that understands that the
journey coming home to access care can be very difficult, so we’re here to build and
bridge the gap between the access to care veterans have and are not using.
This week in Collier County, only 24% of veterans eligible for VA services use those
services. Nationally, the numbers are 35-40%, so there’s a big gap between the number of
veterans who have access to care and who use that care.
Another alarming number is there are about 1.4 million veterans at risk of becoming
homeless on any day.
The diagram you have shows the services we provide veterans.
He applauds the courage Collier County has taken to put this facility in place. It matches
the courage of our veterans, is challenging and The Journey Home wants to be a partner
with Collier County’s veteran services.
There are many great organizations in Collier County that provide veterans services, but
there are many veterans who aren’t using the services and we want to find them.
Thank you for letting us be here to help us find those veterans.
Jacqualene Keay told the BCC:
She did some cursory research on nursing homes in Florida and nationwide and occupancy
and understaffing are the biggest challenges.
She cautions that as they move forward, they need a plan to resolve the occupancy and
staffing issues, or they’ll end up like the other facilities.
50% of the facilities are being used, so we need to be proactive with the staffing-shortage
strategy. Part of that is to build efficiencies or housing, if that is feasible or plausible, near
or onsite.
Another option is to provide a housing allowance. We must find a way to keep and lure
the workforce to Collier County.
She loves the idea that the county is working together as a community to bring this plan to
reality.
She spoke to her facility manager in Indiana, who has years of experience running our
transitional facilities, which provide services to veterans. We came up with some ideas for
ideal services that we can provide.
We want to have dementia, as well as Alzheimer’s care, mental-health, abuse, addiction,
grief and service groups. We talked about military sexual trauma because when you think
about who will be occupying these nursing homes, it’s people her age and generation.
We’re very diverse and we come with complex issues and traumas, so we want to have
services available for those.
We want to provide a purpose to the veterans. They can volunteer around the facility.
They want to feel like they’re serving a purpose, doing something greater than just being
housed in these facilities.
Adult daycare is a great idea, and she’d love to see a VA and clinic annex onsite, as well
as community partnerships. One of the best community partnerships is Golden Paws
Assistance Dogs because a lot of these veterans have service animals.
They could build a dog park for service animals. Those are things to think about.
May 25, 2023
Mr. Mullins apologized for exceeding the two-hour time slot that was advertised. He appreciates the
presenters' patience in getting through this process. It's been very beneficial to everyone involved.
Chairman LoCastro noted that Bob told them they could get an extra 10% and they can summarize
these ideas to the county's benefit. We're full speed ahead. Thanks for bearing with us. You're all
experts in your field. Kurt, we really appreciate all your guidance on the engineering side, and we know
we can learn a lot from the other facilities that have already been built and we've already talked about
maybe visiting one or two others. We don't want the next one, we want the best one. That speaks
volumes about our focus. Bob knows that when we were up in Tallahassee, we talked about not wanting
to get such tunnel vision on a timeline that doesn't build us the best one, so if we need to slide the scale
a bit, it's not stalling. It's making it more advantageous to get the best one, to make sure we measure
twice and cut once. That's our focus.
Commissioner Saunders thanked everybody for participating. John Mullins has the diagrams of our
site, which may be worth sharing with Mike and Kurt, if they haven't already been. Bob has seen them,
and it'll be nice to get other folks here to take a look at that site to make sure we're moving in the right
direction. He's very optimistic about that $72 million. He thought we were going to have to do a new
application, but it sounds like we may be able to stick with that to save a bit of time. He thanked
Commissioners and staff for this very important workshop.
4. Adjourn
There being no further business for the good of the County, the meeting was adjourned by order
of the chairman at 5:21 p.m.
COLLIER COUNTY BOARD OF
COUNTY COMMISSIONERS
Rick LoCastro, Chairman
ATTEST:
CRYSTAL K. KINZEL, CLERK
Attica ae .
These minutes were proved the Commission/Council on 7A1 (.23
as presented or as amended
26